A Theoretical Review of Cognitive Biases and Deficits in Obsessive

Biological Psychology 121 (2016) 221–232

Contents lists available at ScienceDirect

Biological Psychology

jo urnal homepage: www.elsevier.com/locate/biopsycho

A Theoretical review of cognitive biases and deﬁcits in

obsessive–compulsive disorder

∗

Dianne M. Hezel , Richard J. McNally

Department of Psychology, Harvard University, 33 Kirkland St., Cambridge, MA 02138, USA

a r t i c l e i n f o a b s t r a c t

Article history: During the past 30 years, experimental psychopathologists have conducted many studies aiming to elu-

Received 1 July 2015

cidate the cognitive abnormalities that may ﬁgure in the etiology and maintenance of OCD. In this paper,

Received in revised form 29 October 2015

we review research on both dysfunctional beliefs and cognitive deﬁcits in OCD, as ﬁndings from both

Accepted 29 October 2015

traditional self-report and information-processing approaches provide distinct sources of information

Available online 24 November 2015

concerning cognitive abnormalities. First, we discuss dysfunctional beliefs and metacognitive beliefs

implicated in the disorder. Research has identiﬁed a number of maladaptive appraisals (e.g., heightened

Keywords:

responsibility) and metacognitive beliefs (e.g., need to control one’s thoughts) that are associated with

Obsessive–compulsive disorder

the disorder, yet these are not invariably present in all cases of OCD. Next, we review the literature on

Cognitive factors

Memory memory and attentional deﬁcits and biases in OCD. This line of research shows inconsistent evidence for

Attention deﬁcits in memorial and attentional processes, but does indicate that people with the disorder have mem-

Dysfunctional thoughts ory and attention biases that may be related to metacognitive beliefs about their ability to remember and

Metacognition attend to stimuli. Finally, we discuss recent work that suggests that people with OCD have reduced access

to internal states, thus causing them to engage in rituals to resolve persistent uncertainty. Implications

and future directions are discussed.

1. Introduction Salkovskis (1985) developed a cognitive-behavioral model of

OCD by elucidating how people can develop the disorder by

Individuals who suffer from obsessive–compulsive disorder catastrophically misinterpreting the signiﬁcance of normal, dis-

(OCD) are afﬂicted by time-consuming repetitive and intru- tressing intrusive thoughts, thereby explaining how obsessions

sive thoughts, images, and impulses (obsessions) and repetitive originate. His work indicates that most people without OCD occa-

actions (compulsions) that cause signiﬁcant distress and impair- sionally experience intrusive thoughts that do not differ in content

ment (American Psychiatric Association, 2013). Though OCD is from those experienced by people with OCD. Rather, people who

broadly characterized by obsessions and compulsions, it is a develop the disorder seem to misinterpret the signiﬁcance and

very heterogeneous disorder that manifests in a variety of ways. consequences of these thoughts, which leads them to engage in

Researchers have outlined four major symptom dimensions, or compulsions, thereby perpetuating this cycle of obsessions and

subtypes, of OCD, including (1) contamination obsessions and compulsions. Notably, Salkovskis emphasizes the importance of

cleaning compulsions, (2) responsibility for harm obsessions and inﬂated responsibility in this model. He asserts that people with

checking compulsions, (3) symmetry/incompleteness obsessions OCD interpret normal intrusive thoughts as indicative of harm or

and ordering/arranging/repeating compulsions, and (4) aggres- danger and feel responsible for preventing harm to themselves

sive/sexual/religious obsessions (e.g., “unacceptable thoughts”) or others (Salkovskis, 1985; Shafran, 2005). Thus, this feeling of

and mental/checking compulsions (Abramowitz et al., 2010). increased responsibility motivates people to take measures to pre-

Research indicates that different subtypes are associated with dif- vent such harm. According to this model, a man without OCD who

ferent treatment outcomes (Mataix-Cols, Rauch, Manzo, Jenike, & has an intrusive thought of pushing a person in front of an oncom-

Baer, 1999) and thus may be relevant to understanding the mech- ing train would be likely to dismiss the thought as meaningless.

anisms mediating the disorder. However, a man with OCD would interpret the same thought as an

indication that he is dangerous and a true threat to others’ safety.

In an attempt to prevent harm to others, he would then engage in

∗ compulsions (e.g., keeping his hands occupied, praying repeatedly,

Corresponding author.

counting to a lucky number, etc.) that would temporarily decrease

E-mail address: [email protected] (D.M. Hezel).

http://dx.doi.org/10.1016/j.biopsycho.2015.10.012

222 D.M. Hezel, R.J. McNally / Biological Psychology 121 (2016) 221–232

his anxiety. According to Salkovskis’s model, this decrease in anxi- responsibility affects both thoughts and behavior. For example,

ety not only reinforces his compulsive behavior, but also prevents Lopatka and Rachman (1995) placed people with OCD in low and

him from learning that the thought is meaningless and that his high responsibility conditions. The low responsibility situation

anxiety would naturally decrease even without performing com- prompted signiﬁcant decreases in discomfort, panic, and urges to

pulsions (Salkovskis, 1985; Taylor, 2002). Indeed, the attempts to engage in checking behavior; an opposite trend was observed when

suppress the obsessive thought may itself increase its frequency of the same individuals were placed in a high responsibility condition.

occurrence, further reinforcing the man’s belief in his dangerous- Similarly, Ladouceur et al. (1995) asked a non-clinical sample to

ness. perform tasks in both low and high responsibility conditions. The

In his cognitive model of OCD, Rachman (1997) later expanded authors found that individuals in the high responsibility condition

upon Salkovskis’s work to include cognitive biases other than not only experienced an increase in anxiety, but also engaged in

inﬂated responsibility. He theorized that what distinguishes peo- more checking behaviors. In a subsequent study, Ladouceur, Leger,

ple with OCD from those without the disorder is that the former Rheaume, and Dube (1996) treated four OCD patients whose pri-

group makes “catastrophic misinterpretation[s]” (p. 4) of their mary symptoms included checking. Interestingly, the treatment

thoughts, interpreting them as meaningful, signiﬁcant, and threat- consisted of cognitive therapy that speciﬁcally targeted beliefs

ening. Rachman (1997) includes inﬂated responsibility as one of about inﬂated responsibility, but not other dysfunctional thoughts.

the cognitive misappraisals, but also includes others, which we dis- After 32 sessions of treatment, all four patients showed signiﬁ-

cuss later in greater detail. Since the introduction of this cognitive cant improvements in symptoms and three of them maintained

model of OCD, experimental psychopathologists have conducted these gains at 6 and 12-month follow-up. Taken together, these

many studies aiming to elucidate the cognitive abnormalities studies support the link between heightened responsibility and

that may ﬁgure in the etiology and maintenance of OCD. In this obsessive–compulsive symptoms, and suggest that directly target-

article, we review research on both dysfunctional beliefs and cog- ing this cognitive factor may have clinical beneﬁts.

nitive deﬁcits in OCD, as ﬁndings from both traditional self-report In an attempt to understand the etiology of cognitive misap-

and information-processing approaches provide distinct sources of praisals, Salkovskis, Shafran, Rachman, and Freeston (1999) posited

information concerning cognitive abnormalities (McNally, 2001). that there exist a number of pathways that might lead to the

Speciﬁcally, we review work on abnormalities in beliefs, atten- development of heightened responsibility. Pathways outlined by

tion, and memory before discussing a recent line of work on doubt the researchers included recurring experiences, such as growing

and accessing internal states. There is abundant research on the up with rigid rules of conduct, being shielded from responsibility,

biological aspects of OCD, especially neuropsychological studies and being raised with a sense of responsibility for avoiding harm,

on content-independent deﬁcits unrelated to processing of emo- as well as isolated experiences, including incidents in which one

tional information (For a review, see Abramovitch, Abramowitz, & actually does cause harm or erroneously believes that he or she

Mittelman, 2013). However, cognitive neuroscience research con- did. Coles and Schoﬁeld (2008) developed a self-report measure

cerning how the brain mediates information-processing biases and (i.e., the Pathways to Inﬂated Responsibility Beliefs Scale (PIRBS)),

dysfunctional beliefs has only just begun. We discuss this work based on these proposed pathways, and a recent study using this

when relevant with suggestions for future directions. scale indicated that parental overprotection and experiences in

which a person caused or inﬂuenced harm were associated with

stronger OCD-related beliefs and symptoms in a clinical sample

2. Dysfunctional beliefs

(Coles, Schoﬁeld, & Nota, 2014). Findings from additional studies,

using measures other than the PIRBS, likewise suggested that over-

Since Salkovskis (1985) and Rachman (1997) ﬁrst proposed

protective parenting (Smari, Martinsson, & Einarsson, 2010) and

that catastrophic misinterpretations, such as inﬂated responsibil-

feelings of increased responsibility for family members’ protection

ity, might contribute to the onset and the maintenance of the

and happiness (Careau, O’Connor, Turgeon, & Freeston, 2012) were

OCD, many studies have examined different thoughts that might

associated with OCD-related beliefs. Although the aforementioned

be associated with the disorder. Building on early cognitive mod-

studies have found relationships between certain developmental

els, the Obsessive Compulsive Cognitions Working Group (OCCWG)

pathways and cognitive biases, ultimately, the results only offered

was formed to identify and create an assessment of dysfunctional

modest support for Salkovskis et al.’s model, as other pathways

beliefs that are speciﬁc to OCD. In a series of papers, they out-

were not signiﬁcantly and uniquely associated with OCD symp-

lined three domains of dysfunctional beliefs that contribute to the

toms (Coles et al., 2014). Coles et al. (2014) concluded from their

development and maintenance of the disorder, including (1) over-

study that early developmental experiences are likely insufﬁcient

estimation of threat and inﬂated responsibility, (2) importance of

to explain cognitive factors in OCD and that future research should

and need to control thoughts, and (3) perfectionism and intolerance

aim to expand the current etiological model.

of uncertainty (OCCWG, 1997, 2001, 2003, 2005). Numerous studies

Researchers have likewise identiﬁed overestimation of threat as

have demonstrated the importance of these dysfunctional beliefs

a signiﬁcant cognitive distortion in individuals with OCD. This con-

in OCD, and research within these domains continues. A descrip-

struct includes dysfunctional beliefs about the likelihood of danger

tion of each of these domains appears below, followed by a general

occurring in general and about personal vulnerability to aversive

discussion of how dysfunctional beliefs are related to OCD.

events (Moritz & Pohl, 2009; OCCWG, 1997). A series of studies

suggest that individuals with the disorder do not actually overesti-

2.1. Inﬂated responsibility & overestimation of threat mate the likelihood of aversive OCD (e.g., a contamination item asks

about the number of new HIV infections documented in Germany

Conceptualized as the belief that one is responsible for pre- in a given year) and non-OCD events in general, but rather lack an

venting harm or other negative outcomes, inﬂated responsibility “unrealistic optimism” (Moritz & Pohl, 2009, p. 5) bias, the belief

has been identiﬁed as a signiﬁcant cognitive distortion in OCD. that one is less vulnerable to harm and more likely to experience

As noted above, Salkovskis (1985) emphasized the importance of positive events than are others. Indeed, ﬁndings from three stud-

inﬂated responsibility in his cognitive model of OCD, and since ies showed that OCD subjects overestimate the likelihood of harm

then, many studies have shown its association to OCD symp- befalling them and experience less relief than do those without the

toms in clinical and non-clinical samples (Salkovskis et al., 2000). disorder when presented with actual statistics about the low fre-

Indeed, research suggests that manipulating beliefs about personal quency of harmful events (Moritz & Jelinek, 2009; Moritz & Pohl,

D.M. Hezel, R.J. McNally / Biological Psychology 121 (2016) 221–232 223

2006). This pattern of thinking may help to explain why people with tions commonly associated with OCD. The authors state that TAF

OCD are especially risk averse (Admon et al., 2012). That is, if these may cause people with OCD to feel a heightened responsibility for

people feel more vulnerable to harm, then it seems reasonable they preventing harm, to assess negative events as especially costly, and

would make a greater effort to avoid potentially dangerous situa- to experience “overvalued ideations” (p. 5), or the belief that obses-

tions and engage in compulsions to decrease potential threat to sions have the ability to cause harm (Kozak & Foa, 1994). Indeed,

themselves, even though such behaviors give them a false sense of Rachman (1993) asserted that thought-action fusion may arise

security and instead serve to reinforce their maladaptive thoughts when misinterpretations of thoughts interact with an exaggerated

and behaviors (Moritz & Pohl, 2009). sense of responsibility for preventing harm, and a subsequent study

Beliefs about excessive responsibility imply fear of experienc- (Rachman, Thordarson, Shafran, & Woody, 1995) found that TAF

ing guilt (or shame) from harming others or failing to prevent emerged as one of four factors of responsibility. TAF is now con-

harm. This theme has motivated studies relevant to moral reason- sidered to be a related, but separate, construct from heightened

ing in OCD. For example, Franklin, McNally, and Riemann (2009) responsibility, and research suggests that TAF may trigger unre-

presented OCD patients and healthy control subjects with moral alistic beliefs about preventing harm and vice versa (Shafran &

dilemma scenarios involving two options: a utilitarian option Rachman, 2004).

whereby one chooses to sacriﬁce the life of one person to save A number of studies suggest that heightened levels of thought-

the lives of others, and a deontological option whereby the subject action fusion have also been associated with pathological worry

refuses to harm another, resulting in the indirect deaths of others. and negative affect, even in the absence of OCD symptoms

The groups did not differ in terms of the rate of choosing the utili- (Abramowitz, Whiteside, Lynam, & Kalsy, 2003; Hazlett-Stevens,

tarian option. However, the higher the scores on the Responsibility Zucker, & Craske, 2002). Although this distorted belief is not unique

Attitude Scale within the OCD group, the less likely were patients to OCD, studies have modeled how the belief may contribute

to choose to kill one person to save the lives of others. to the maintenance of the disorder. For example, van den Hout,

Using functional magnetic resonance imaging (fMRI) to target Kindt, Weiland, and Peters (2002) demonstrated that a behavioral

brain regions implicated in moral reasoning, Harrison et al. (2012) TAF task, in which subjects were asked to write out a disturbing

exposed OCD patients and healthy control subjects to moral scenar- sentence (e.g., “I hope my sister is in a car accident”) increased

ios while in the scanner. Replicating Franklin et al., they found that people’s urge to neutralize their thoughts (Shafran & Rachman,

the groups did not differ in their endorsement rate of the utilitarian 2004). Attempting to neutralize one’s thoughts, in turn, leads to

option. Although both groups exhibited robust activation in frontal more intrusive thoughts, thereby maintaining the cycle of obsessive

and temporoparietal regions of the brain, the OCD group exhibited thoughts and compulsive behaviors (Rachman & Hodgson, 1980).

heightened activation of the ventral frontal cortex, especially the If people appraise their thoughts as signiﬁcant and potentially

medial orbitofrontal cortex. Moreover, the patients also exhibited dangerous, it follows that they will attempt to resist or control

heightened activation in the left dorsolateral prefrontal cortex and such thoughts to prevent harm to themselves or others (Rachman &

left middle temporal gyrus. These data suggest that OCD patients Hodgson, 1980). Hence, belief in the over-importance of thoughts

respond to moral dilemmas with ampliﬁed neural activation even seems related to the need to control them (OCCWG, 1997). The

though they do not differ from healthy control subjects in how they metacognitive belief that one must control one’s thoughts is asso-

say they would resolve the dilemma. ciated with higher frequency of obsessive thoughts in non-clinical

subjects (Clark, Purdon, & Wang, 2003). Additionally, the OCCWG

2.2. Over-importance of and need to control thoughts (2001) found that OCD subjects score higher on thought control

subscales than do healthy individuals and people with other anx-

The importance of thoughts refers to the distorted belief that iety disorders (Purdon & Clark, 2002). This cognitive distortion

simply having a thought means that it is signiﬁcant or that it reﬂects prompts people to attempt to control their thoughts with maladap-

a person’s desires or true nature (OCCWG, 1997). A speciﬁc mis- tive strategies such as compulsions or thought control techniques

appraisal that falls within this category and has garnered a lot (e.g., thought suppression, worry) that paradoxically trigger further

of attention is thought-action fusion (TAF; e.g., Berle & Starcevic, intrusive thoughts (Purdon & Clark, 2002). Though classiﬁed as a

2005). This cognitive bias consists of two subtypes: (1) TAF moral, dysfunctional belief by some researchers, the importance of and

the belief that thinking about doing something bad is the moral need to control thoughts also lies as the heart of the metacognitive

equivalent of engaging in the corresponding action (e.g., thinking theory of OCD discussed below.

about stabbing my husband is the moral equivalent of harming

him) and (b) TAF-likelihood, the belief that thinking about a nega- 2.3. Perfectionism and intolerance of uncertainty

tive outcome occurring increases its likelihood (e.g., thinking about

my sister dying in a car crash increases the chances of its hap- Intolerance of uncertainty (IU) refers to the distress one

pening; Rachman, 1993; Shafran, Thordarson, & Rachman, 1996; experiences in ambiguous or unpredictable situations (Boswell,

Rachman & Shafran, 1999). TAF-likelihood can be further catego- Thompson-Hollands, Farchione, & Barlow, 2013; OCCWG, 1997;

rized as either “likelihood self,” the belief that thoughts will result Sarawgi, Oglesby, & Cougle, 2013). Individuals who have a low

in negative outcomes for oneself, or “likelihood-other,” the belief tolerance for uncertainty tend to “ﬁnd uncertainty stressful

that one’s thoughts will cause danger to befall other people. and upsetting, believe that uncertainty is negative and should

In their early cognitive models of OCD, Salkovskis (1985) and be avoided. . .experience difﬁculties functioning in uncertainty-

Rachman (1993) observed that people with OCD often believe that inducing situations. . . and [consequently] engage in futile attempts

their thoughts and actions are intertwined, and Shafran et al. (1996) to control or eliminate uncertainty” (Buhr & Dugas, 2009, p.

later created the Thought-Action Fusion Scale to examine the pres- 216). Moreover, experimentally inducing intolerance of uncer-

ence of these thoughts in people with the disorder. Subsequent tainty increases worry (Buhr & Dugas, 2009; Ladouceur et al., 2000),

studies have indicated that OCD is associated with elevated levels and the association between IU and worry remains strong even

of TAF, particularly TAF-likelihood (Berle & Starcevic, 2005; Shafran after one controls for other variables, such as responsibility and

& Rachman, 2004; Shafran et al., 1996). Interestingly, a study by anxiety sensitivity (Dugas, Gosselin, & Ladouceur, 2001). Unsur-

Amir, Freshman, Ramsey, Neary, and Brigidi (2001) suggests that prisingly, then, IU has been identiﬁed as a transdiagnostic feature

TAF extends to beliefs about the power of thoughts to prevent harm common to generalized anxiety disorder, social anxiety disorder,

from befalling others, and may contribute to other cognitive distor- panic disorder, and OCD. Furthermore, reductions in IU correlate

224 D.M. Hezel, R.J. McNally / Biological Psychology 121 (2016) 221–232

with reductions in anxiety symptoms from pre- to post-treatment symptoms. Moreover, structural equation modeling indicated that

(Boswell et al., 2013). certain beliefs were predictive of different symptoms. The authors

Individuals with OCD have a low tolerance for uncertainty found that dysfunctional thoughts about threat estimation and

(Holaway, Heimberg, & Coles, 2006), and high scores on self-report heightened responsibility predicted the presence of six different

measures of IU predict discomfort following a range of OCD-related OCD symptoms (i.e., ordering, checking, neutralizing, obsessing,

in vivo tasks (e.g., ordering, checking, contamination in non-clinical hoarding, and washing), whereas beliefs about perfectionism and

subjects; Sarawgi et al., 2013). Indeed, people with OCD may engage intolerance of uncertainty were associated only with ordering rit-

in compulsions, especially checking, in an attempt to resolve their uals, and beliefs about the importance of and need to control

uncertainty associated with an obsession (Tolin et al., 2001). For thoughts were predictive only of obsessive thoughts and wash-

example, a man might doubt whether he locked the door to his ing and neutralizing behavior. Corroborating other studies, this

house and thus continue checking it in an attempt to feel more cer- study suggests that cognitive biases are more pronounced in some

tain that it is actually locked. However, this temporary reduction subtypes of OCD than in others, thus underscoring the heterogene-

in uncertainty comes at a great cost, as compulsions are nega- ity of the disorder (Abramowitz, Lackey et al., 2009; Taylor et al.,

tively reinforced, rendering the person vulnerable to even more 2010; Tolin, Woods, & Abramowitz, 2003). Indeed, in some stud-

frequent obsessions and subsequent compulsions (Abramowitz, ies, subgroups of OCD subjects were no more dysfunctional in their

Taylor, & McKay, 2009). Moreover, people with OCD often avoid thinking than were control subjects (Calamari et al., 2006; Taylor

situations that could potentially trigger their obsessions or com- et al., 2006). Hence, dysfunctional thoughts may play a role in only

pulsions, or continually seek reassurance from others to alleviate certain individuals with the disorder.

their uncertainty, thereby perpetuating the cycle of obsessions and Though most research examining the role of cognitive distor-

compulsions (Kobori & Salkovskis, 2013). tions is based on cross-sectional studies, several researchers have

Finally, perfectionism refers to the dysfunctional belief that one conducted prospective studies to determine if the presence of such

must meet exceedingly high standards accompanied by persistent beliefs predicts the development of OCD symptoms. Abramowitz,

concern over making mistakes, which are viewed as failures (Frost, Khandker, Nelson, Deacon, and Rygwall (2006) assessed 100 par-

Novara, & Rheaume, 2002). Long thought to be associated with ents three months prior to and three months following the birth of

OCD, perfectionism may be an attempt to avoid negative outcomes, their ﬁrst child, as ﬁrst-time parents are particularly vulnerable to

such as uncertainty, and to gain some control over one’s environ- developing obsessive–compulsive symptoms, especially intrusive

ment (Frost et al., 2002). As with the other maladaptive beliefs thoughts about their newborns. The study revealed that the severity

described above, perfectionism is associated with OCD symptoms of dysfunctional beliefs prior to the birth predicted the sever-

in both non-clinical and clinical populations (Frost, Steketee, Cohn, ity of post-partum OC symptoms, especially obsessing, checking,

& Griess, 1994; Rheaume, Ladouceur, & Freeston, 2000), and seems and washing, even after Abramowitz et al. controlled for baseline

especially relevant to checking compulsions and “not just right” measures of anxiety, depression, and OC symptoms. In another

experiences (Coles, Frost, Heimberg, & Rheaume, 2003; Moretz prospective study, baseline levels of cognitive distortions predicted

& McKay, 2009). Moreover, a study by Bouchard, Rheaume, and OC symptom severity six weeks later in a non-clinical sample (Coles

Ladouceur (1999) indicated that perfectionism may cause peo- & Horng, 2006). Consistent with prior research, the study also

ple to feel a heightened responsibility for negative events. Hence, showed that certain maladaptive beliefs (e.g., heightened responsi-

dysfunctional beliefs about perfectionism and responsibility may bility) had more predictive power of OC symptoms than did others.

interact to exacerbate obsessive–compulsive symptoms. However, a later study failed to replicate these ﬁndings in a six-

month prospective study of a non-clinical sample (Coles, Pietrefesa,

2.4. Dysfunctional beliefs and OCD Schoeﬁeld, & Cook, 2008). Although dysfunctional beliefs predicted

distress associated with OC symptoms, they did not predict the fre-

Given the prominence of dysfunctional beliefs in cognitive and quency of these symptoms. Hence, more research on the causal

cognitive-behavioral theories of OCD, a great deal of research has relationship between thoughts and symptoms is warranted.

investigated the speciﬁc relationship between these biases and

the disorder. Steketee, Frost, and Cohen (1998) found that OCD

subjects endorsed higher levels of dysfunctional thinking, as mea- 2.5. Summary

sured by self-report measures, than did healthy control subjects or

people with other anxiety disorders. Though the anxious control Early cognitive models and clinical observations of OCD pos-

group was also characterized by elevated dysfunctional thinking, tulated that dysfunctional thoughts ﬁgure prominently in the

the association of beliefs about responsibility, threat estimation, development and maintenance of the disorder. Since then, a great

uncertainty, and need to control thoughts were more strongly deal of research has conﬁrmed that these thoughts are frequently

related to OCD. More recently, Abramowitz, Lackey, and Wheaton associated with obsessive–compulsive symptoms in both non-

(2009) examined the relationship between experiential avoidance, clinical and clinical populations, and that the relationship among

dysfunctional beliefs, and OCD symptoms in non-clinical under- speciﬁc thoughts and symptoms might vary (e.g., perfectionism

graduate students. Using the Obsessive Compulsive Inventory, the is more strongly associated with checking symptoms than with

authors categorized subjects into one of two groups: high OC symp- contamination symptoms). Though the etiology of thoughts is still

toms or low OC symptoms. The high OC group had greater levels of unclear, studies show that targeting these beliefs can, in turn, affect

dysfunctional thinking than did the low OC group, and these beliefs subsequent thoughts and behavior. Indeed, cognitive therapy is

predicted obsessive thinking and checking rituals even after the an effective treatment for OCD (Wilhelm et al., 2009), and reduc-

authors controlled for other factors. These beliefs predicted vari- tions in dysfunctional beliefs mediate reduction in OCD symptoms

ance in OCD symptoms and severity of compulsions in patients with in cognitive therapy (Wilhelm, Berman, Keshaviah, Schwartz, &

the disorder (Taylor, McKay, & Abramowitz, 2005). Steketee, 2015). However, other studies have questioned the causal

To elucidate the relationship between dysfunctional thoughts direction of reduced beliefs and symptom improvement (Woody,

and speciﬁc obsessive–compulsive symptoms, Taylor et al. (2010) Whittal, & McLean, 2011), and have found cognitive therapy to

conducted a study on a large non-clinical sample of students be less effective than behavioral therapy at reducing OCD symp-

from ﬁve different universities across the United States. In agree- toms (Olatunji et al., 2013). Hence, a better understanding of these

ment with previous research, distorted beliefs predicted OC thoughts, their development, and how they relate to speciﬁc OCD

D.M. Hezel, R.J. McNally / Biological Psychology 121 (2016) 221–232 225

subtypes may result in even more effective and targeted treatments on a measure of obsessive symptoms. Subjects were told that an

for the disorder. EEG machine could indicate when they were thinking about water.

Finally, in a thoughtful, provocative critique of the After viewing some videos about water, subjects in the experimen-

Salkovskis–Rachman cognitive model, Cougle and Lee (2014) tal condition were told that they would hear an unpleasant noise

mention further concerns additional to those we raise in our when the EEG machine detected thoughts about water, whereas the

review (e.g., determining whether presumed cognitive causes other half was told they would hear this noise randomly, unrelated

are epiphenomenal correlates of the disorder). For example, to any speciﬁc thoughts. Findings indicated that subjects in the

they observe that the standard cognitive model presupposes experimental condition who had greater OC symptoms were more

that intrusive thoughts are benign occurrences that only become likely to experience intrusive thoughts about water, felt more dis-

problematic in virtue of individuals appraising them catastrophi- comfort when these thoughts arose, and spent more time thinking

cally. Yet they provide evidence suggesting that many repugnant about these intrusive thoughts. This study suggests that it is possi-

intrusive thoughts do not require catastrophizing to render them ble not only to induce metacognitive thoughts, but also that doing

pathological; some are inherently so. Yet they, and we, agree that so can cause people who have high levels of obsessional thinking

the cognitive model has been richly heuristic even though its to experience OCD-like symptoms.

limitations are becoming apparent. Finally, reducing negative metacognitive thinking mediates

symptom improvement in individuals suffering from OCD. Solem,

Haland, Vogel, Hansen, and Wells (2009) found that changes in

3. Metacognitive model metacognitive thoughts, as measured by the Metacognitions Ques-

tionnaire (Wells & Cartwright-Hatton, 2004), predicted symptom

Like the cognitive model, the metacognitive model of OCD improvement in patients treated with exposure with response pre-

emphasizes the etiological importance of dysfunctional thoughts. vention. This factor remained signiﬁcant after controlling for other

However, the metacognitive model, ﬁrst proposed by Wells and factors such as baseline OCD severity, mood, and overlap with non-

Matthews (1994), distinguishes between beliefs about the world, metacognitive thoughts.

such as perfectionism and heightened responsibility, and metacog-

nitive beliefs about one’s thoughts, such as the importance of

3.1. Summary

and need to control thoughts. Speciﬁcally, the model asserts that

“metacognitive beliefs are central to the development and mainte-

The metacognitive model of OCD acknowledges that dysfunc-

nance of OCD. . . [whereas] cognitive beliefs [are] by-products of the

tional thoughts have an important role in the development and

effects metacognitive beliefs have on processing” (Myers, Fisher,

maintenance of the disorder, but underscores the central role of

& Wells, 2009, p. 133; for a complete review of the metacogni-

metacognitive beliefs such as thought fusion. Studies have indi-

tive model, see Fisher, 2009). The theory states that not only do

cated that metacognitive beliefs may engender OCD symptoms,

these thoughts trigger dysfunctional appraisals and anxiety, but

and that this association remains after researchers control for

also motivate individuals to devise a coping strategy, which con-

non-metacognitive beliefs and other variables. However, metacog-

sists of rumination, thought monitoring, hypervigilance to threat,

nitive thoughts are more strongly associated with OCD in groups

and compulsive behaviors that are often terminated according to

of patients with high levels of dysfunctional (non-metacognitive)

other metacognitive beliefs (e.g., when he or she “feels” or “knows”

thinking than with OCD patients with low levels of dysfunctional

it is okay to do so; Fisher, 2009).

thinking (Chik, Calamari, Rector, & Riemann, 2010). Therefore, as

Like cognitive theorists, proponents of the metacognitive theory

with the cognitive theory of OCD, the metacognitive theory may

have identiﬁed the importance of and need to control thoughts as

only apply to a subgroup of people with the disorder. Finally, in

an especially important etiological fact; unlike cognitive theorists,

an important extension of the metacognitive model, Exner, Martin,

however, they underscore the importance of the metacognitive

& Rief (2009) have shown that monitoring one’s thoughts are an

nature of the belief. Researchers have developed a measure, the

important cause of memory deﬁcits common in OCD, as we discuss

Thought Fusion Instrument (Wells, Gwilliam, & Cartwright-Hatton,

below.

2001), that assesses three components of this belief: thought event

fusion, thought action fusion, and thought object fusion (Fisher,

2009). Thought event fusion is the belief that thinking about an 4. Cognitive deﬁcits and information-processing biases

event makes it more likely to happen or signiﬁes that it did happen

(e.g., having a thought about a hit and run car accident indicates Unlike much of the research on dysfunctional beliefs and

that the person is responsible for such an accident). Thought action metacognition, research on cognitive deﬁcits and information-

fusion refers to the belief that having a thought of doing something processing biases do not rely on self-report, but rather on

will cause the person to act on the thought even if he or she has no behavioral measures such as reaction time and neuropsychologi-

desire to do so (e.g., thinking of stabbing a friend will make a per- cal assessment (McNally, 2001). Consequently, this line of research

son more likely to do so). Finally, thought object fusion is the belief may reveal important etiological information about the disorder

that thoughts can be transferred to inanimate objects (e.g., negative that is not readily accessible to patients’ awareness. Early exper-

thoughts can contaminate an object, which can then contaminate imental research examined the possibility that individuals with

other people). OCD have deﬁcits in various cognitive processes such as memory,

Several cross-sectional studies have shown that metacogni- reality monitoring, and attention (Muller & Roberts, 2005). Con-

tive beliefs predict OCD symptoms. Moreover, thought fusion sidering the repetitive nature of obsessions and compulsions, it

prospectively and independently predicted OCD symptoms in is possible that people with OCD have impairments in how they

college students even after controlling for worry and other dys- attend to threatening versus non-threatening information (atten-

functional thoughts, whereas non-metacognitive beliefs did not tion), in remembering if they completed an action (memory), and in

independently predict OCD symptoms (Myers et al., 2009). More knowing if they performed an action or simply imagined it (reality

recently, Myers and Wells (2013) found that inducing metacogni- monitoring; Muller & Roberts, 2005). These deﬁcits may be espe-

tive beliefs in a non-clinical sample caused individuals to develop cially relevant in certain subtypes of OCD, such as those that involve

obsessive–compulsive symptoms. The researchers recruited col- checking rituals. Indeed, if a person has difﬁculty remembering if

lege students who scored in the upper quartile or lower quartile she checked the door to ensure it is locked, then she may continue to

226 D.M. Hezel, R.J. McNally / Biological Psychology 121 (2016) 221–232

check it repeatedly until she can be certain it is properly secured. In Another experiment produced broadly similar effects; OCD

addition to reviewing deﬁcits on memory, reality monitoring, and patients exhibited a decline in visual memory performance after

attention, we also include a review of a more recent line of research having encoded complex designs during induced CSC or during the

on deﬁcits in accessing one’s internal states. auditory secondary task versus no concurrent task (Kikul, Vetter,

Lincoln, & Exner, 2011). Interestingly, the healthy control group

exhibited memory deﬁcits only after encoding the complex ﬁgures

4.1. Memory during the auditory secondary task, whereas CSC induction did not

decrement their performance relative to the no concurrent task

Research on memory deﬁcits in OCD has garnered mixed sup- condition.

port. Some studies involving neuropsychological measures, such as CSC again produced verbal memory deﬁcits in people with

the Wechsler Memory Scale (WMS) and the California Verbal Learn- OCD in an experiment showing that similar deﬁcits occurred

ing Task found that individuals with the disorder performed worse in people with major depressive disorder (Weber et al., 2014).

than did people without OCD on verbal recall, but not recognition, Taken together, these studies suggest that deﬁcits in memory per-

tasks (Muller & Roberts, 2005). Deckersbach, Otto, Savage, Baer, and formance in people with OCD (and depression) are attributable

Jenike (2000) found that deﬁcits in verbal and non-verbal mem- to a metacognitive habit of monitoring one’s thoughts, thereby

ory performance apparently arise from suboptimal organizational consuming cognitive resources essential for robust encoding of

strategies that OCD patients often use when they attempt to mem- material that one must recall later.

orize material. Hence, the memory deﬁcits appear to arise from an Reality monitoring denotes the process whereby people dis-

encoding deﬁcit. Yet other studies failed to detect deﬁcits in verbal criminate mental content arising from perception from that arising

memory performance (Christensen, Kim, Dysken, & Hoover, 1992; from imagination. A reality monitoring deﬁcit might cause the

Dirson, Bouvard, Cottraux, & Martin, 1995; Muller & Roberts, 2005), uncertainty that drives people with OCD to repeatedly check

whereas another that matched non-depressed OCD and healthy whether they performed a certain action correctly. Some stud-

subjects on age, gender, and education found no signiﬁcant dif- ies show that people with sub-clinical (Rubenstein, Peynircioglu,

ferences on verbal memory, as measured by the Wechsler Adult Chambless, & Pigott, 1993) and clinical (Merckelbach & Wessel,

Intelligence Scale (WAIS) and the WMS, but did detect a relative 2000) OCD have difﬁculty recalling if they had performed certain

deﬁcit in the OCD group in nonverbal memory (Christensen et al., actions or simply imagined performing them (Muller & Roberts,

1992). Indeed, OCD subjects have exhibited deﬁcits on nonverbal 2005). Yet other studies suggest that the problem lies elsewhere.

memory tasks more consistently than on verbal ones (Christensen For example, McNally and Kohlbeck (1993) found no differences

et al., 1992; Deckersbach et al., 2000). Deckersbach et al. (2000) and in reality monitoring abilities between OCD patients, including

Christensen et al. (1992) found that people with OCD performed checkers, and healthy comparison subjects, but they did ﬁnd that

below the general population norm and worse than healthy con- OCD patients reported less conﬁdence in their abilities to dis-

trol subjects, respectively, on nonverbal memory tasks as measured tinguish actions they performed from those they had imagined

by neuropsychological batteries. Moreover, Savage et al. (1999) performing relative to comparison subjects. Other studies have

found that individuals with OCD demonstrated worse performance conﬁrmed that people with OCD, especially those with check-

on measures of nonverbal memory, including the WAIS and the ing rituals, lack conﬁdence in their memories rather than having

Rey-Osterrieth Complex Figure Task. In the latter task, subjects are deﬁcits in reality monitoring (Nedeljkovic & Kyrios, 2007) rela-

shown a complex ﬁgure and then asked to draw it from memory tive to people without the disorder (Hermans, Martens, De Cort,

immediately after seeing it and then again after a 30-min delay. Pieters, & Eelen, 2003; Muller & Roberts, 2005; Olley, Malhi, &

Consistent with Deckersbach et al. (2000) study, Savage et al. (1999) Sachdev, 2007; Tolin et al., 2001). Indeed, decreased conﬁdence

found that disorganized encoding strategies mediated OCD sub- could explain apparent memory impairments in OCD (Radomsky

jects’ poor performance on these non-verbal memory tasks (Savage & Rachman, 2004). That is, people with OCD may believe they

et al., 1999). They concluded that people with OCD are more likely have memory problems when they merely lack conﬁdence in their

to focus on “irrelevant details of to-be remembered items,” (Savage memory.

et al., 1999, p. 914) which in turn impairs their recall of that infor- In fact, repeated checking can actually decrease one’s memory

mation later. conﬁdence. Tolin et al. (2001) found that with repeated checking,

Cross-sectional data indicate that cognitive self-consciousness OCD subjects who were asked to repeatedly observe and recall

(CSC), a propensity to monitor one’s thinking, characterizes peo- different objects demonstrated a decline in memory conﬁdence

ple with OCD and distinguishes them from those with other for ideographically selected threatening items. This decrement did

anxiety disorders and those free of mental disorders (Janeck, not occur in anxious and non-anxious control groups. Similarly,

Calamari, Riemann, & Heffelﬁnger, 2003). Presumably motivating using virtual gas burners and light bulbs, van den Hout and Kindt

this tendency are maladaptive metacognitive beliefs about the dan- (2003b) measured subjects’ ability to recall turning off gas burn-

gerousness of intrusive thoughts. As Exner et al. (2009) noted, ers before and after instructing them to repeatedly manipulate

chronically monitoring the content of one’s thoughts consumes and check relevant (gas burners) or irrelevant (light bulbs) stimuli.

cognitive capacity, and thereby may impede the encoding and sub- Although memory accuracy was not affected by repeated checking,

sequent retrieval of information from memory. Moving beyond individuals who were asked to repeatedly check a relevant stimu-

correlational studies, Exner et al. have conducted experiments lus reported lower memory conﬁdence in and decreased vividness

whereby they induce CSC in people via instructing them to mon- and detail of their memories of turning off the gas burners. The

itor their thoughts during subsequent tasks (e.g., encoding words authors replicated their ﬁndings in two additional independent

for later recall). In one study, they found that inducing CSC during studies and concluded that repeated checking increases familiar-

word encoding impaired subsequent verbal memory performance ity with an object, which subsequently interferes with bottom-up

as much as a dual-task condition whereby subjects monitored audi- processing of the object’s details such as color and shape, thereby

tory digit strings for the number 9 (Kikul, Van Allen, & Exner, 2012). reducing the detail and vividness of memories of the object (van den

Importantly, they found that inducing CSC consumes capacity as Hout & Kindt, 2003b). Importantly, this study was conducted with

traditional dual-task paradigms do; instructional induction of CSC a non-clinical sample, and thus indicates that repeated checking

produces verbal memory deﬁcits in healthy subjects that mimic the can cause memory distrust in individuals without OCD symptoms.

deficits often occurring in people with OCD. A recent study identified a similar pattern of findings in a clinical

D.M. Hezel, R.J. McNally / Biological Psychology 121 (2016) 221–232 227

sample that was asked to repeatedly check real, functioning stoves OCD completed the task both before and after undergoing treat-

and faucets (Radomsky, Dugas, Alcolado, & Lavoie, 2014). ment, which consisted of 15 sessions of exposure and response

In subsequent replications, van den Hout and Kindt (2003a, prevention. Patients detected threat words more than neutral, and

2004) found that repeated checking shifted the basis of their mem- exhibited increased skin conductance responses upon detecting

ory from remembering that they performed an action to knowing threat targets relative to neutral targets. This bias favoring threat

that they must have performed it. As Tulving (1985) observed, words vanished after treatment. Yet subsequent studies on atten-

people may believe that an event occurred either because they tional bias for threat in OCD have yielded mixed ﬁndings

remember speciﬁc details about the event (e.g., “I remember turn- In studies using the emotional Stroop task, subjects are pre-

ing the gas knob with my right hand and watching the ﬂame go sented with neutral or threat-related words that are typed in

out”) or know it happened based on a previously established pat- various colors and are asked to name the color of the words while

tern of behavior (e.g., “I always turn off the stove when I’m done ignoring their meanings. Yet when the meaning of the word cap-

using it”). Indeed, after repeated checking, study subjects were tures the subject’s attention despite the subject’s effort to attend

more likely to endorse statements about knowing the gas burner to its color, subjects exhibited delayed color-naming of the word

was off but having a fuzzy or unclear memory of turning it off (van (MacLeod et al., 1986; Muller & Roberts, 2005). Two early stud-

den Hout & Kindt, 2003a). ies using the modiﬁed Stroop task found that subjects with OCD

Some studies suggest that individuals with OCD may have demonstrated an attentional bias to OCD-related words (Foa, Ilai,

improved memory (i.e., a memory bias) for threat-related words McCarthy, Shoyer, & Murdock, 1993; Lavy, van Oppen, & van den

and actions (Brown, Kosslyn, Breiter, Baer, & Jenike, 1994; Constans, Hout, 1994). Interestingly, a more recent study asked individuals

Foa, Franklin, & Mathews, 1995; Merckelbach & Wessel, 2000). with and without OCD to read neutral and ideographically threat-

Constans et al. (1995) found that individuals with checking com- ening passages prior to completing the standard, non-emotional

pulsions had better recall for anxiety-inducing items they had Stroop task in order to investigate the effect of anxiety on atten-

manipulated than did people without OCD, whereas Brown et al. tion (Cohen, Lachenmeyer, & Springer, 2003). Findings indicated

(1994) and Merkelbach and Wessel (2000) observed that OCD sub- that people with OCD responded more slowly than did non-OCD

jects outperformed healthy controls on reality monitoring tasks. subjects on the Stroop task in both the neutral and anxiety con-

Though other researchers have failed to ﬁnd a memory bias in ditions, but that their performance declined substantially in the

OCD, Radomsky and Rachman (1999) point out that the majority latter condition. The authors concluded that situational anxiety

of these studies failed to use stimuli that are both threatening and can impair people’s attention on subsequent tasks, even when

relevant to the OCD subjects tested. Accordingly, they examined the task involves non-OCD stimuli as measured by a neutral, non-

whether individuals with contamination obsessions and wash- threatening Stroop task (Cohen et al., 2003).

ing compulsions have a memory bias for “contaminated” objects. Other studies using the Stroop task have failed to ﬁnd evidence

Findings indicated that the OCD group had better recall for con- of attentional bias in OCD subjects. For example, Kyrios and Iob

taminated items than they did for uncontaminated items; this (1998) found no signiﬁcant differences between OCD and non-OCD

memory bias was not observed in either the anxious or healthy subjects’ performance on both a masked and unmasked Stroop task.

control group. In a subsequent study, Radomsky, Rachman, and Indeed, both healthy and OCD subjects had faster color-naming

Hammond (2001) detected a memory bias for threatening infor- times to threatening and positive stimuli in the unmasked con-

mation in people with checking rituals, but only under conditions dition than in the masked condition. However, the authors point

of high responsibility (i.e., when the subjects felt that they, and not out that the control group had high levels of trait anxiety, which

the experimenter, were responsible for checking). These studies may help to explain the lack of differences between the groups.

underscore the importance of using stimuli that are signiﬁcant and Moreover, the OCD sample was characterized by high levels of

threatening in order to detect memory biases in OCD. The authors’ depression, which may have further complicated the results (Kyrios

ﬁndings are consistent with research on information processing & Iob, 1998; Muller & Roberts, 2005). Similarly, Moritz et al. (2008)

“which predict that increased attentional and memorial resources found no evidence of bias on an emotional Stroop in OCD washers

are allocated to process information relevant to a person’s current and checkers relative to a healthy control group; rather, OCD wash-

emotional state” (p. 820). ers showed faster color-naming responses to OCD washing-related

stimuli than did healthy control subjects. Though these ﬁndings do

4.2. Attention not provide support f or attentional bias in people with OCD, the

authors note that the threatening words were not idiographic to

Just as people with OCD have memory biases for relevant, threat- individual OCD subjects and that words alone may be insufﬁcient

ening stimuli, so too do they demonstrate attentional biases for to elicit a bias (Moritz et al., 2008). Other studies have likewise

threatening information (Bar-Haim, Lamy, Pergamin, Bakermans- found no evidence of bias on the emotional Stroop task (Kampman,

Kranenburg, & Van, 2007; MacLeod, Mathews, & Tata, 1986). Keijsers, Verbraak, Naring, & Hoogduin, 2002; Moritz et al., 2004).

Indeed, information-processing models of anxiety hold that peo- However, in a neuroimaging study, van den Heuvel et al. (2005)

ple with anxiety disorders are hypervigilant to emotionally salient found that subjects with OCD made more errors on a standard,

information, which in turn, prevents them from attending to other non-emotional Stroop task than did healthy individuals or subjects

important stimuli in their environment (Muller & Roberts, 2005; with panic disorder or hypochondriasis. Interestingly, OCD sub-

Radomsky & Rachman, 2004). Though OCD is no longer classi- jects did not demonstrate an attentional bias to OCD-threat words

ﬁed as an anxiety disorder in the most recent revision of the DSM on the emotional Stroop task, but did show a unique pattern of

(American Psychiatric Association, 2013), people with the disorder neural activity, including increased activation of the anterior cin-

typically experience high levels of anxiety, and attentional biases gulate cortex and limbic regions, on fMRI. These results suggest

have been associated with the disorder (Muller & Roberts, 2005). that although biases may not always be observable with behav-

One of the ﬁrst investigations of attentional biases in OCD (Foa & ioral measures of attention, individuals who suffer from OCD tend

McNally, 1986) used a dichotic listening task, during which sub- to process relevant, threatening stimuli differently than do people

jects were presented with two simultaneous recordings (one in without the disorder (van den Heuvel et al., 2005). Nevertheless,

each ear) and were asked to repeat one of the passages while also the frequent absence of an emotional Stroop interference effect in

indicating when they heard certain target words that were neu- OCD contrasts with its presence in other anxiety-related disorders

tral (e.g., “pick”) or threatening (e.g., “feces”). Nine individuals with (Bar-Haim et al., 2007).

228 D.M. Hezel, R.J. McNally / Biological Psychology 121 (2016) 221–232

Despite these very mixed ﬁndings for the emotional Stroop in extends beyond mere uncertainty or an exaggerated need for

OCD, Thomas, Gonsalvez, and Johnstone (2013) administered this certainty. Finally, it conceptualizes compulsive rituals as compen-

task with disorder-relevant threat words to patients with OCD, satory substitutes for signals of internal states that are readily

patients with panic disorder, and healthy control subjects while accessible to those without OCD. Hence, rituals do not merely

measuring the subjects’ event related potentials (ERPs) to these reﬂect a futile attempt to obtain certainty, safety, or a sense of

stimuli. Although only the panic disorder group exhibited signif- completeness, per se.

icantly longer color-naming latencies to their threat words, the These researchers have devised ingenious laboratory methods

OCD group did exhibit larger P1 amplitudes and long N1 laten- for measuring attenuated access to internal states (Lazarov et al.,

cies to threat versus neutral words, suggestive of preferential early 2012a). In their latest study, they had OCD patients, patients with

attentional capture by threat cues. anxiety disorders, and healthy control subjects perform a two-part

The dot-probe task is another common measure of attentional electromyographic (EMG) study testing for diminished access to

bias for threat (MacLeod et al., 1986), in which individuals respond muscle tension in the forearm (Lazarov, Liberman, Hermesh, &

to a probe that replaces either a neutral or threat-related word on a Dar, 2014). The researchers ﬁrst attached EMG electrodes to the

screen (MacLeod et al., 1986). Researchers assert that if people are subject’s forearm and then trained them to produce four levels of

hypervigilant to threat, they will respond more quickly to the probe target muscle tension deﬁned by microvolt levels. In Phase I, they

when it replaces threatening words than when it replaces neu- asked subjects to produce each of these levels repeatedly in random

tral words. Tata, Leibowitz, Prunty, Cameron, and Pickering (1996) order, and they measured the absolute magnitude of the discrep-

administered the dot-probe task to people with high-trait anxi- ancy between the target level and the level produced by the subject.

ety, low-trait anxiety, and contamination-related obsessions and In Phase II, subjects received visual biofeedback informing them of

compulsions. Their results showed that OCD subjects were faster how close their muscle tension was to the target level. In Phase

to detect probes preceded by contamination-related words, but not III, they eliminated the biofeedback, and again asked them to pro-

to social anxiety-related words, whereas individuals with high-trait duce target levels of tension as in Phase I. Phase IV was identical to

anxiety exhibited the opposite pattern; the low-trait anxiety group Phases I and III except that the experimenter told subjects that on

showed no bias to either group of words. A more recent study failed certain trials they would have the option to view the biofeedback

to ﬁnd a similar bias in OCD subjects with checking symptoms monitor, but that doing so might produce a distracting noise that

(Harkness, Harris, Jones, & Vaccaro, 2009), thus suggesting that could impair their attempt to produce the correct level of muscle

attentional biases for threat may occur only for certain subtypes of tension.

OCD. In another dot-probe study, Amir, Najmi, and Morrison (2009) Consistent with SPIS, OCD subjects produced markedly more

found that attentional biases for idiographic (personally-relevant) discrepant levels of muscle tension in Phases I and III relative to

threat words in subclinical OCD subjects waned over the course of target levels and relative to both the anxiety disorder and healthy

the experiment as subjects apparently habituated to threat cues. control subjects. Yet when all three groups received the proxy of

By experiment’s end, they exhibited no more bias for threat than biofeedback in Phase II, the OCD subjects produced tension lev-

did subjects with minimal OCD symptoms. Amir et al. suggested els that were just as accurate as those of the other two groups.

this waning effect may explain inconsistent ﬁndings across studies In Phase IV, OCD subjects requested to see the biofeedback moni-

in OCD subjects; it also raises serious questions about the stabil- tor more than the other groups did, despite the possibility that it

ity of attentional bias for threat, at least as measured by dot-probe might interfere with their performance. Taken together, these data

performance. indicate that impaired access to the internal state of muscle ten-

sion in OCD and that reliance on the external proxy of biofeedback

4.3. Pervasive doubt and diminished access to internal states entirely compensates for this deﬁcit. Notably, analyses indicated

that comorbid anxiety disorders and depression could not account

Pervasive doubt is a hallmark of OCD, ranging from uncertainty for these ﬁndings. Finally, the second part of the study indicated

about whether one performed certain actions to uncertainty about that OCD subjects were fooled by false feedback of muscle tension

one’s general knowledge (Dar, Rish, Hermesh, Taub, & Fux, 2000). far more than the other groups were, again conﬁrming that OCD

This cognitive abnormality seemingly drives checking, reassurance patients rely on external proxies to judge their internal states. These

seeking, and other tactics designed to diminish distressing doubt. studies replicated previous ﬁndings showing that college students

Lazarov, Dar, Liberman, and Oded (2012a) have suggested that such scoring high on questionnaire measures of OCD exhibit perfor-

doubt may originate in difﬁculty accessing internal states includ- mance deﬁcits in the muscle tensing task except when receiving

ing cognitive (e.g., memory, comprehension), affective (e.g., speciﬁc biofeedback (Lazarov, Dar, Liberman, & Oded, 2012b). However,

emotions, attraction), and bodily (e.g., muscle tension) ones. To the magnitude of performance impairment is markedly greater in

compensate for attenuated access, people with OCD seek proxies the OCD patients than in the high-OC-symptom college students

for internal states that can resolve their uncertainty. Not only may (Lazarov et al., 2014).

checkers ask others whether doors are locked or stoves turned off,

but individuals with OCD may rely on external stimuli, behaviors, 4.4. Summary

or rules as proxies for other internal states unrelated to threat. For

example, a man who is uncertain whether he loves his wife may Research fails to provide consistent support for memory deﬁcits

tally the number of times he sends her text messages as an “opera- in individuals with OCD, though there is compelling evidence that

tional” measure of love. A person uncertain of whether she believes metacognitive beliefs may motivate people to constantly monitor

in God may use her frequency of praying as evidence of belief. their own thoughts, thereby negatively impacting memory perfor-

These objective measures are reminiscent of the economist’s use mance. Moreover, people with the disorder seem to have decreased

of behavior as “revealed preference” for the inaccessible desires of conﬁdence in their memory and have memorial and attentional

consumers in a market economy. biases for relevant, threatening stimuli. The evidence for mem-

The seeking-proxies-for-internal-states (SPIS) hypothesis holds ory bias in OCD is more robust than for attentional biases, but

that difficulty accessing internal states is not confined to disorder- researchers provide a number of explanations for inconsistent find-

relevant themes such as uncertainty about contamination, harm ings, as outlined above. Speciﬁcally, they highlight the importance

to others, responsibility, or morality. Rather, it is a content- of using relevant, idiographic stimuli to elicit group differences,

independent deﬁcit relevant to any internal state. Moreover, it and raise the possibility that habituation to threat may attenuate

D.M. Hezel, R.J. McNally / Biological Psychology 121 (2016) 221–232 229

biases over time. Moreover, there is evidence that though biases the neurobiological correlates of the cognitive abnormalities asso-

may not be readily observable on behavioral tasks of attention, pat- ciated with OCD. We reviewed several studies above that attempt to

terns of neural activation suggest differences in how people with elucidate more about the neurobiology of attentional biases in peo-

OCD process threatening stimuli. ple with the disorder by using fMRI and EEG, but there is a general

Stronger evidence for cognitive deﬁcits in OCD comes from dearth of research on the topic. That OCD is such a heterogeneous

recent research on doubt and difﬁculty accessing internal states. disorder likely contributes to the challenges of studying the neu-

As a result of this apparent deﬁcit, people with the disorder tend ral correlates of cognitive biases in this population. It would thus

to rely on external proxies, thereby explaining why they engage be worthwhile to identify groups of patients with shared biases

in ritualistic behavior. Though still in its early stages, this unique (e.g., attentional biases, thought-action fusion, etc.), rather than by

line of research provides a promising avenue for understanding OCD diagnosis alone, in order to more directly test how these spe-

the cognitive abnormalities that may contribute to the onset and ciﬁc abnormalities are manifested in the brain. Moreover, research

maintenance of OCD. on depression has revealed that hyperactivation in certain brain

regions is associated with cognitive biases in depressed individ-

uals with a speciﬁc gene variant (Beck, 2008). Though no single

5. Future directions gene has been found to confer risk for developing OCD, combin-

ing research from genetics and neuroimaging studies may result

In this article, we reviewed cognitive processes implicated as in a better understanding of cognitive processes and their neural

aberrant in OCD, including dysfunctional thoughts, metacognitive correlates.

beliefs, and cognitive deﬁcits. Though we discussed these processes Finally, as researchers embark upon studies of the biological

separately, they are likely interrelated. For example, metacogni- correlates of cognitive abnormalities they should heed the cau-

tive theorists assert that certain beliefs, such as thought fusion, tions articulated by Miller (2010) in his brilliant critique of the

can lead to other non-metacognitive beliefs such as heightened conceptual confusions that abound in the cognitive neuroscience

responsibility and intolerance of uncertainty. They also posit that of psychopathology today. To be sure, cognition is implemented

these metacognitive beliefs cause people to ruminate about threat, in the brain, but that does mean that cognitive biases and deﬁcits

which in turn, could foster attentional biases or memory biases are the epiphenomenal consequences of biological processes that

for threat (Fisher, 2009). It is likewise feasible that such thoughts, many researchers mistakenly characterize as more “basic” phe-

which lead to cognitive self-consciousness, account for the afore- nomena that “underlie” or cause the cognitive features of OCD.

mentioned memory and internal conviction deﬁcits as noted above. Although researchers may discover regular patterns in neurobiol-

Beliefs about the importance of having a perfect memory or hav- ogy that accompany obsessions and compulsions, imputation of

ing complete access to one’s internal states combined with a lack dysfunction to these patterns presupposes that we have anchored

of conﬁdence in one’s ability to do so could interfere with perfor- these observations in the clinical phenomenology of OCD. One can-

mance on these types of tasks, thus leading individuals to ritualize not identify a neuroimaging ﬁnding as “dysfunctional” on its own;

to achieve certainty. Therefore, there may exist a hierarchy of a neurobiological difference can qualify as a potential neurobio-

cognitive processes whereby certain thoughts can explain other logical dysfunction only in virtue of its regular covariation with

cognitive abnormalities in individuals with OCD. Indeed, Hirsch, clinical abnormalities identiﬁed psychologically (McNally, 2001).

Clark, and Mathews (2006) proposed a “combined cognitive biases” And even then, we cannot assume that the neurobiological dif-

hypothesis for social anxiety disorder. The theory, which has since ference is the cause of the psychological difference that produces

been applied to depression as well (Everaert, Koster, & Derakshan, suffering in people with OCD. All we can say for sure is that they

2012; Everaert, Tierens, Uzieblo, & Koster, 2013), asserts that dif- occur together.

ferent cognitive biases affect and interact with one another to

maintain a given disorder. To our knowledge, no studies have

explicitly tested this theory in OCD. Doing so may further elucidate References

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